Pediatric WIC Referral FormSECTION I:Complete this section to assist the patient with wlc eligibility, wtc seruices, and appropriate referrals whenever a therapeutic formula is prescribed, complete both Sections I and ll.PATIENT NAME - FirstLastDate of Birth Date Format: MM slash DD slash YYYY CURRENT HEIGHT/LENGTH:(within 60 days)inchesCURRENT WEIGHT:(within 50 days)lbslbsozoz
